I would like to contribute per quarterly billPlease note you will be charged this full amount on your next and subsequent quarterly bill.

Title

First Name *

Last Name *

Date of Birth *

DayMonthYear

Ergon Energy Account Number *

Email Address *

Home

Work

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Your Consent/Authority

Consent *

I agree for Ergon Energy to set up/amend my Clean Energy contribution. Ergon Energy has the authority to charge the agreed contribution amount per electricity bill. This consent/authority is valid until Ergon Energy is notified of its cancellation, change or amendment by me.